Suicide ideation - experiences of adversely racialised people: research

7.1 Appendix 1 – Literature review

Exploring Suicide Ideation and Completion in Racialised Groups in Scotland

Introduction

Since 1990, Scotland has had a higher suicide completion rate in the UK overall (ScotPho, 2020). In August 2018, the Scottish Government published the national suicide prevention plan: Every Life Matters. The plan lists ten actions that partners in mental health and suicide prevention, leaders at local, regional, and national level must take to transform Scotland's response and perceptions towards suicide. Through the successful implementation of these ten actions, the plan sets to reduce the rate of suicide in Scotland by 20% by 2022. The plan adopts a multi-sectoral approach that extends beyond social care and healthcare agencies. By recognising the need for collective action to prevent deaths by suicide in the country.

To support the successful delivery of the plan the Scottish Government instituted the National Suicide Prevention Leadership Group (NSPLG) that oversees the plan's ten actions. This piece of work will support Action 7 of the plan. Action 7 seeks to identify and facilitate preventative actions targeted "at risk" groups. During the completion of initial activities under action 7, several gaps in engagement in the work to date were identified. One such gap was engaging and exploring the experiences of suicide ideation and completion in racialised groups. As a result, this piece of work seeks to explore the factors that influence the suicide ideation or attempts in racialised groups in Scotland. Summers (2018) reports that racialised groups in Scotland face unequal access to mental health services and lack specialised support. However, there is a lack of research on the mental health experiences in racialised groups, in Scotland. As a result, a furthermore objective of this work is to explore the appropriateness and perceived barriers to access of mental health services for racialised groups in Scotland.

Perceptions of Mental Health in Racialised Groups

Mental Health Stigma

Developing suicide prevention interventions, and exploring suicide ideation, attempts and completion in racialised groups. Is incomplete without understanding the perceptions of mental health held by this group. Stigma towards mental health illnesses remains a constant feature in some racialised groups (Knifton, 2012; Gunson et al, 2019). Whether it is mild cases of depression and anxiety or severe cases of schizophrenia and bipolar, and in the worst cases suicide. In some racialised groups, there are long standing beliefs that mental health illnesses are a taboo or perceived a concern for the western world (Gunson et al, 2019; Gervais et al, 2010). Some racialised groups believe that enduring tough or traumatic experiences are a sign of strength and resilience.

Anything less is considered weakness, and the onset of mental health illnesses are considered punishment for breaking spiritual or moral laws (Armstrong, 2019; Gervais et al, 2010).

Stigma towards mental ill health has created a reluctance in individuals from racialised groups to seek support to treat mental ill health symptoms (Memon et al, 2016). Dr Asif Khan, a GP in West Scotland, reported to BBC Scotland, that over a fifth of his workload is mental health related, and patients he supports from racialised groups always show an initial reluctance to seek mental health support. Once they have overcome their initial fears, they will describe their challenges by listing everything they are experiencing, like family stress, financial difficulties, housing stress etc, besides acknowledging that they may be experiencing symptoms of mental ill health (BBC Scotland, 2018).

Ethnic variations define what acceptable responses and coping mechanisms to mental health illnesses are for racialised groups. For some racialised groups, issues of mental ill health are ignored or perceived as a socially unacceptable topic of discussion. In instances where the topic is discussed, individuals with mental health illnesses are labelled "mad" or "crazy" or "psycho" (Memon et al, 2016; BBC Scotland, 2018). For example, a patient in Glasgow reported to BBC Scotland that she kept quiet about her mental health challenges because mental health issues are not spoken about or accepted in her community (BBC Scotland, 2018). Suggesting that discussing pertinent issues like suicide would be more difficult.

Mental health issues remain a least discussed topic in some racialised groups because the consequences of mental health stigmatisation extend beyond the individual and can affect an individual's entire family Memon et al, 2016; Armstrong, 2019; Choo et al, 2017). For example, negative mental health framing that results from cultural myths asserting that mental ill health is a sign of bad luck. Result in individuals ignoring mental health distress. To prevent their social stigmatisation in their communities (Memon et al, 2016; Gervais et al, 2010).

Research suggests that Scotland's current public education programmes have been slow to transform perceptions towards mental health in racialised groups (Brook, 2018). Owing to this research, improving mental health education and support has been one of the top priorities on the policy agenda of the Scottish Government and related agencies (See Me Scotland, 2020). With a key priority being to diversify the pathways for public mental health education and awareness. That ensures that programmes engage with "hard to reach" communities in the country, like racialised groups (Quinn and Knifton, 2014).

For example, the Scottish Mental Health Arts Festival (SMHAF), launched in 2017, that has been effective in engaging with diverse groups to challenge stigma towards mental health. The reach of these festivals has led to the Scottish Government, NHS boards and other mental health agencies incorporating these festivals as a central part of their mental health improvement strategies and anti-stigma campaigns, i.e. the SMHAF is a central part of the Scottish Government's national anti-stigma "see me" campaign. However, to ensure transformative change, Turakhia and Combs (2017) suggest there is a need for the Scottish Government, NHS boards and other mental health agencies to prioritise co-producing mental health awareness campaigns and services with service users from racialised groups. Involving service users in the planning and implementation processes has the potential to improve mental health outcomes and service experiences for racialised groups.

Perceived Factors Driving Suicide Ideation or Completion in Racialised Groups

Socio-Cultural Factors

Intergenerational strife, marriage, sexism, cultural factors, domestic and substance abuse, and adverse experiences in the host country have been identified as key triggers of mental ill health in racialised groups (BBC Scotland, 2018). McLaughlin (2016) and Mental Health Foundation (2020) report that socio-cultural factors like gender-role expectations and domestic violence are key mental ill health triggers in South Asian communities. For example, research by Forte et al (2018), Bhui et al (2011) and Barnett et al (2019) reports high levels of anxiety and depression in South Asian individuals attributed to stressful family environments. While Rethink Mental Illness (2020) and Bamford et al (2020) suggests that risk factors like poor housing, homelessness and social deprivation perpetuate mental health illnesses and suicide ideation in African and Caribbean migrants.

Hate Crimes

Studies have suggested that there is an increased risk of mental ill health such as depression, anxiety and psychotic disorders in immigrants as compared to native individuals of a host country (Bamford et al, 2020). In Scotland, post migration stress and experiences of hate crimes are key triggers of mental ill health, self-harm, and suicide ideation and attempts in racialised groups (Hate Crime Scotland, 2020). Racial crime was the most reported hate crime in Scotland, in 2019-20, accounting for 3,038 charges (BBC Scotland, 2020). With many more cases believed to go unreported. Hate crimes exacerbate mental health conditions in individuals and make it increasingly difficult for individuals to assimilate into Scottish society and live a high-quality life.

Hate Crime Scotland (2020), Penrice et al (2019) and Hall (2017) report that crimes motivated by discrimination and prejudice have damaging effects for survivors, their families, and communities. Feelings of anger, shame, mistrust, fearlessness, depression, and anxiety are all common effects experienced by survivors of hate crimes. These in turn may negatively impact on many areas of a survivor's life including education, employment, health, and relationships. For migrants without close family or friends in Scotland, experiencing hate crimes compound feelings of isolation, not belonging, or being accepted in society seem to perpetuate mental ill health and suicide ideation and attempts.

Racism

Racism is a trauma and an unpleasant and unfortunate reality of racialised groups in Scotland. Racialised individuals experience racism in society and through systems. There is a growing body of evidence that demonstrates that racism leads to mental ill health like severe depression, prolonged grief and periods of adjustment, and difficulty processing traumatic events (Kwato and Goodman, 2015). Research highlights a strong association between racism and suicide ideation and attempts in racialised groups.

Furthermore, the repeated experience of suicide and discrimination reduces an individual's ability to overcome suicidal behaviour (Mental Health Foundation, 2009).

Institutional racism in mental health organisations has been a growing concern in Scotland. For example, the inequalities seen in mental health service delivery provided to racialised groups. Institutional racism in mental health services is seen through the consistent pattern of unequal services and outcomes for racialised groups for decades (The Synergi Collaborative Centre, 2018; BBC Scotland, 2018). Demonstrated through greater involuntary detentions of racialised individuals made by unevidenced criteria, and harsher psychiatric diagnosis and treatment options in comparison to White counterparts (Barnett et al, 2019; BBC, 2019). The fear of racism that would be reflected in unequal mental health services is a real concern for racialised groups and has created a reluctance in these individuals seeking support.

In Scotland, mental health organisations like Saheliya, Mental Health Foundation Scotland, VOX, REACH, CRER, BEMIS, SAMH and Rethink Mental Health Illnesses are some of the organisations that have been vocal about the need to for the Scottish Government and mental health agencies to acknowledge the diverse factors experiences of racialised groups that increase an individual's propensity to mental ill health and suicide ideation. Furthermore, through mental health awareness campaigns, events and reports, these organisations have advocated for the need of specialised mental health services for racialised groups to be created.

Through desktop research of these organisations. REACH, Saheliya, Rethink Mental Health Illnesses and the Mental Health Foundation Scotland appear to be the only organisations that acknowledge racism as one of the key factors that lead to mental ill health in racialised groups. With REACH and the Mental Health Foundation Scotland being the only organisations that have published reports that expand on the effect of racism on the mental health of racialised groups (REACH, 2008; Mental Health Foundation, 2009). Suggesting that there is a need for all mental health organisations that aim to provide mental health support to racialised groups to fully explore the factors that result in mental ill health and suicide ideation or attempts for this group, like racism. Furthermore, this would suggest as racism may be experienced interpersonally and structurally, providing appropriate mental health support for racialised groups in Scotland is incomplete without exploring and addressing racism in mental health services.

REACH published a report titled Mental Health Issues amongst Muslim Women Residing in South East Glasgow Community Health and Care Partnership Boundary: A Study of Their Beliefs, Knowledge and Service Access Issues in November 2008. The report has a brief section on racism and discrimination. In which it highlights that racism negatively effects the mental health and suicide behaviours of the individuals. Furthermore, it explores the experiences of racism the individuals have endured and highlights that racism has made the participants reluctant to seek mental health support (REACH, 2008).

The Mental Health Foundation published a report titled Model Values? Race, values, and models in mental health in 2009. The report repeatedly highlights the fact that racism negatively affects mental health of individuals and may negatively affect mental health diagnosis/treatment and various aspects of an individual's life (King et al, 2009). This suggests there is a need to further explore the association between racism and suicide ideation/ completion in racialised groups.

Migration

In recent years, the Scottish Government and mental health agencies have been concerned with exploring the health and mental health needs of racialised groups like asylum seekers, refugees and migrants in Scotland (Scottish Government, 2020; Mental Health Foundation, 2016). Research has highlighted mental ill health as a prevalent issue for refugees and asylum seekers in Scotland. Furthermore, research has identified worsening of mental health among refugees since arriving in the UK. With pre- and post-migration stress identified as one of the key factors of mental ill health among these groups (Mental Health Foundation, 2016; BBC, 2017).

Pre-migration experiences that some refugees and asylum seekers have endured like torture, various forms of violence and other traumatic events in their home counties have negatively impacted on their mental health. These issues are compounded by the asylum and refugee processes. Key stresses of the process are the uncertainty of an individual's case, enforced economic inactivity and dependency on charities or government for everyday needs while seeking asylum (Mental Health Foundation, 2016; ScotPHN, 2016). Often, an asylum seekers or refugees stress does not end there. Once an individual is granted leave to remain in the UK, they face additional barriers accessing employment due to ethnic variations. As a result, this compounds their feelings of insecurity and uncertainty, which increases the severity of their mental health illnesses and propensity to suicide (Mental Health Foundation, 2016).

Refugees and asylum seekers that are not granted leave to remain and do not appeal their cases are faced with deportation and held in deportation detention centres around the UK. Research by the BBC's Victoria Derbyshire programme found an unequal appeal process for racialised asylum seekers and refugees. In that the success of their appeal cases are dependent on which centre their application is lodged to. Some legal supervisors have expressed similar concerns by reporting that there could be numerous cases that have merit for success, but still each could have a different outcome depending on the location of the centre, cultural differences between applicant and decision makers, and based on different judges. The stress and uncertainty caused by these unjust processes compound mental health distress in asylum seekers and refugees and have the potential to lead to suicide ideation and attempts (BBC, 2017; Mental Health Foundation; 2016).

Research by Rubin (2020) states that according to the Home Office's policies, vulnerable individuals and survivors of torture and traumatic events should not otherwise be detained. Such as refugees or asylum seekers. Furthermore, following concerns about the high suicide rate in the UK detention centres and the detention of vulnerable individuals. The Home Office developed a new Adult at Risk policy for people held in detention under immigration. Rule 35 underpinning the policy intends to ensure that potential vulnerable individuals are examined by a medical practitioner and detention is maintained only if it is necessary. However, evidence suggests that many adult asylum seekers and refugees who had a rule 35 report were still detained and are classified as vulnerable adults across the UK's deportation detention sites. The stress of detention and pending deportation has worsened mental health conditions of detainees and increased their propensity to suicide ideation and attempts. It is reported that suicide attempts have become more common in the UK deportation detention centres, with two attempts being recorded every day in 2018. 56% of which were committed by detainees who were classified as vulnerable adults (Rubin, 2020; The Guardian, 2018).

In Scotland organisations like the Mental Health Foundation Scotland, Saheliya, REACH and Rethink Mental Illness have focused on providing mental health support to asylum seekers, refugees and racialised migrants in other categories. These organisations have focused on creating awareness of the unequal immigration processes these groups face and the pre-migration adverse events these groups experience. For example, discrimination and racism experienced by migrants at immigration facilities or through immigration decisions. Furthermore, they have focused on improving health education campaigns to reduce mental health stigma in these groups and provide specialised mental health support for racialised individuals in need (Mental Health Foundation, 2020; Saheliya, 2020; REACH, 2020; Rethink Mental Health Illness, 2020). However, migration stress and challenges do not seem extensively explored by most mental health agencies that seek to support racialised groups. There seems a need, for organisations to acknowledge the effect of hostile immigration processes in the UK on the mental health of migrants, and how the worsening mental health conditions and propensity to suicide occurs because of these.

Housing and Homelessness

Housing issues and homelessness are identified as key factors of mental ill health in racialised groups (Mental Health Foundation, 2020). Although there is considerable diversity in the circumstances of racialised groups with regards to housing issues. The common housing problems include obtaining information about housing options and rights due to language needs, a lack of familiarity and access to the system and institutional discrimination (Anderson, 2019; The Migration Observatory, 2019). In Scotland, racialised groups are underrepresented in social housing and overrepresented in privately rented properties (Joseph Rowntree Foundation, 2020; Netto et al, 2011). However, these houses tend to be poor quality housing. There is a need for social housing agencies to be more representative in their lettings, to ensure that racialised individuals are not inadvertently or consciously disadvantaged in social housing allocations (Joseph Rowntree Foundation, 2020). This suggests a need to prioritise racialised groups in activities to improve access to quality housing. Evidence suggests that poor housing and various housing issues increase an individual's propensity to mental ill health (Anderson, 2019). Suggesting that housing stress has the potential to lead to suicide ideation and attempts.

Perceived Barriers to Accessing Mental Health Support for Racialised Groups

Cultural Competence

To implement effective suicide prevention strategies for racialised groups, it is important to explore the availability of appropriate mental health services and perceived barriers of access for this group. Access to appropriate mental health services for racialised groups in Scotland has been a cause for concern. Evidence suggests that racialised groups are less likely to obtain appropriate mental healthcare services in the country. Furthermore, fewer individuals from racialised groups are referred for specialised psychiatric services, and individuals who are referred tend to be over treated or sectioned under the Mental Health Act. (BBC Scotland, 2018; Barnett et al, 2019).

Adverse experiences with mental health services are consistently reported by racialised service users in Scotland (BBC Scotland, 2018). With the lack of cultural competence by services providers, considered a key barrier to accessing mental health services for racialised groups (Gunson et al, 2019; Memon et al, 2016). It seems a significant proportion of service providers have had limited ability to deliver mental health support that meets the social, cultural and language needs of patients from racialised groups. Evidence suggests that racialised individuals are reluctant to seek support from mental health specialists because they lack an understanding their cultural experiences, which is reflected in their inability to sympathise with the diverse realities of racialised individuals (Memon et al, 2016; Choo et al, 2017). Thereby affecting the appropriateness of services provided to racialised groups.

Research suggests that the cultural competence of mental health service and practitioners may be one of the key factors that can improve mental health help-seeking behaviour in racialised groups (Royal College of Psychiatrists, 2020). Evidence suggests that racialised individuals are less likely to seek support for mental ill health at an early stage due to a lack of culturally appropriate services (Barnett et al, 2019; Memon et al, 2016). As a result, many individuals seek treatment much later, when their conditions are more severe. Worsening mental ill health conditions, compounded by additional daily stresses an individual may experience, increases an individual's propensity to suicide ideation and attempts (Choo et al, 2017).

The literature suggests it's imperative for mental health agencies to acknowledge that delivering culturally appropriate services extends beyond an organisation ensuring that their staff attends mandatory trainings on cultural competency in mental health. There seems an urgent need to for mental health organisations and related agencies to prioritise ensuring an ethnically diverse and representative workforce of psychologists and psychiatrists. The literature suggests an ethnically diverse workforce is imperative for improving the mental health help-seeking behaviour and overall experiences of mental health services for racialised groups in Scotland (York, 2020). Furthermore, it seems imperative for addressing the unequal clinical outcomes for racialised groups in the country (Haigh et al, 2014; York, 2020). A similar study in the field, conducted in the UK, reported that when accessing mental health services the majority of the study participants would prefer to see a practitioner of the same ethnicity, who would understand their culture and experiences (Memon et al, 2016). Therefore, suggesting that ensuring a diverse workforce to deliver suicide prevention interventions should be a key component of incoming strategies.

Communication and Responding to Patient Needs

Language is a common barrier to access for racialised groups. The inability of some individuals to communicate effectively with mental health practitioners prevents individuals from clearly articulating their challenges and could lead to misdiagnosis (Memon et al, 2016; Forte et al, 2018). Although interpreter services are better provided for in recent years and have helped with miscommunication. There is a lack of interpreters available to support the full body of patients with language needs, and practitioners need to be aware of the potential challenges for their use (Haigh et al, 2014; Ahmad and Tabassum, 2009). For example, Green et al (2007) suggests that patients are less likely to discuss their health challenges through an interpreter. Languages needs may result in individuals being reluctant to seek mental health services for those who have barriers in communication and may result in patients withdrawing from support facilities, mainly because patients feel they are not receiving their desired support (Memon et al, 2016; Forte et al, 2018).

Barriers to communication do not only arise from linguistic challenges of racialised groups. The perceived inability of practitioners to listen to the concerns of service users pose additional barriers to access of appropriate mental health services for racialised service users (Choo et al; 2017). For example, in the UK, it has been reported that when engaging with mental health practitioners racialised patients were often treated with a generalised approach and prescribed higher doses of medication, irrespective of the patients' attempts to express their reluctance of taking medication to treatment their symptoms and their desire to explore alternative therapies (Memon et al, 2016; Mind, 2020). Similarly, it has been suggested that racialised groups in Scotland are given unequal mental health support and harsher treatment options, that lead to worse mental health outcomes (BBC Scotland, 2018). Therefore implying that to avoid unfavourable outcomes, there is a need for targeted and person-centred mental health support to be provided for racialised groups.

Mental Health Sectioning

Evidence suggests that racialised mental health patients are at risk of being given harsher psychiatric diagnosis's and are more likely to be sectioned under the Mental Health Act (Barnett et al, 2019). Professor Sashi Sashidharan, a consultant psychiatrist in Scotland, reported to the BBC Scotland that racialised groups have the worst experiences with mental health services in Scotland. Furthermore, service providers either do not take the challenges of these groups seriously or section individuals and provide them with extreme forms of treatment (BBC Scotland, 2018).

Research suggests that patients from racialised groups are disproportionately at risk of involuntary psychiatric detention in the UK (Barnett et al, 2019). Studies in the field that assessed the effect of location as a predictor of involuntary psychiatric detention of racialised groups. Reported a significantly higher probability of involuntary psychiatric detentions of racialised individuals who are UK based in comparison to other countries (Ajnakina et al, 2017; Barnett al, 2019). In March 2019, black people were four times more likely than white people to be sectioned under the Mental Health Act in the UK (Scottish Government, 2019).

The main explanation for the high prevalence of involuntary sectioning in racialised groups is an increased prevalence of psychosis in these groups (Mann et al, 2014). While unevidenced explanations for involuntary psychiatric detentions are increased perceived risk of violence and demographic assumptions of racialised groups (i.e. greater drug use) (Pheobe et al, 2019). However, according to the Mental Health Act, psychosis alone is not a criterion for involuntary detention. Furthermore, using unevidenced assumptions to enforce involuntary psychiatric detention of individuals who could have benefited from more appropriate treatment options, results in worse mental health outcomes. Due to the trauma of sectioning or harsher treatments (Mind, 2020; Mann et al, 2014; Bignall et al, 2020). Suggesting that there is a need for further investigation into mental health consultations of racialised individuals that resulted in involuntary psychiatric detention.

These frequent adverse experiences of racialised groups with mental health services, has built distrust in the services for these groups, and created misconceptions in some racialised groups that seeking support from mental health services "will not result in recovery by could result in death" (Fanin, 2017). This results in individuals suffering in silence and presenting for mental health treatment late, when their cases are more severe (Bignall et al, 2020).

Due to the concerns that practitioners have the power, with the simple stroke of a pen, to decide whether an individual will be sectioned or receive appropriate treatment (Memon et al, 2016). For example, Fanin (2017) reports a case where a woman from a racialised group, in the UK, reported to the hospital to seek support for mental distress and suicidal thoughts she was experiencing. However, her case was not taken seriously, and instead she was sectioned which compounded the mental distress she experienced. Such cases may highlight deeper systemic issues and subconscious racial bias, that perpetuate unequal access to mental health services and unfavourable mental health outcomes for racialised groups.

To improve mental health help-seeking behaviour and implement effective suicide prevention strategies in racialised communities the literature seems to indicate that mental health practitioners and agencies should begin to acknowledge the genuine and realistic fear of being sectioned or receiving harsher psychiatric treatment as a key barrier to access for racialised groups. Furthermore, to prioritise changing this narrative and building trust in racialised groups, through addressing the persistent systemic issues that result in unequal mental health services and mental health outcomes for this groups.

Data and Literature

Suicides are among the most preventable causes of death if the risk factors are identified early and appropriate interventions are applied promptly (Forte et al, 2018; NICE, 2012). One of the greatest dangers is that of not recognising the "red flags" or treating the absence of traditional risk factor signs, as confirmation of the absence of the risk of a suicide ideation or possible attempt (Bhui et al, 2011; NICE, 2012). Research suggests that effective suicide prevention strategies targeted at racialised groups are those that are culturally informed and understand the ethnic variations of expressing mental distress (Choo et al, 2017; NICE, 2012). For example, Choo et al (2017), NICE (2017) and Forte et al (2018) suggest that while depressive symptoms may be a key risk indicator of suicide ideation and attempts for one ethnicity, sudden consistent social isolation may be a risk indicator for another. Suggesting that exploring the ethnic variation of expressing mental distress should be a focus of mental health agencies prior to designing and implementing suicide prevention interventions targeted at racialised groups.

In Scotland, the lack of systematic data on the use and experiences of mental health services by ethnicity prohibits mental health practitioners and agencies, health boards and the Scottish Government from understanding the true extent of barriers faced by racialised groups (Summers, 2018). Furthermore, it prevents these agencies from responding effectively and ensuring access to appropriate mental health services for racialised groups (Barnett et al, 2019). Similarly, there is a lack of systematic data on suicide by ethnicity. Although, personnel conducting inquests into suicide do not record ethnicity because they are not required to. Without this data to shed light on the true extent of the problem, it is difficult to ensure that responding agencies are implementing appropriate suicide prevention interventions targeted at racialised groups (Choo et al, 2017; NICE, 2012).

To date, extensive research on suicide and mental health in minority groups has not been conducted in Scotland. Research has focused mainly on exploring the mental health experiences and suicide in minority groups like the LGBT+ community and individuals with learning disabilities. It seems that there has been a lack of urgency to explore the mental health experiences and suicide of racialised minority groups in Scotland.

Although, grey literature from NGOs targeted at supporting racialised groups in Scotland, have been instrumental in creating awareness of the disparities in mental health services for racialised groups, there is a need for research to prioritise exploring the mental health experiences of racialised groups extensively. This could help to ensure that mental health interventions targeted at racialised groups are designed based on evidence-based research rather than generalised statistics.

Pathway to Mental Health Support

The pathways to suicide support appear to be unclear or poorly communicated to racialised groups, as far as general mental health support is concerned. The pathway for mental health support for racialised groups appears problematic. Evidence suggests that mental ill health in some racialised individuals are often ignored in primary care facilities. Furthermore, there is evidence that racialised individuals are afforded mental health care pathways that unnecessarily result in contact with the police (The Synergi Collaborative Centre, 2018). Research suggests that racialised groups are less likely to receive primary care management for mental health symptoms and more likely receive care through the criminal justice system. When patients are taken to the police due to a "perceived risk" of harm to themselves or others, an individual could have a longstanding personality disorder and have diagnoses that are influenced by racialised stereotypes (The Synergi Collaborative Centre, 2018). This pathway may have resulted in a high prevalence of involuntary detentions in racialised groups and worsening mental health conditions for affected individuals. Furthermore, these adverse experiences have negatively impacted mental health help-seeking behaviour in racialised groups (The Synergi Collaborative Centre, 2018; BBC, 2019; Barnett et al, 2019).

Generally, the first contact with mental health support services for racialised groups is through organisations that have community-based activities. For example, SAMH who engage with racialised communities in East Glasgow through their Community Strides project. That project seeks to support individuals from racialised communities to be included in their communities and receive adequate support for their mental health and physical health through the power of physical activity. REACH conducts various projects that focus on engaging with racialised groups in communities around Scotland, to provide mental health support, community physical and mental outdoor activities, and holistic support for other aspects of an individual's lives. Similarly, Saheliya conducts an array of activities and provides mental health support to racialised groups. BEMIS provides multilingual and ethnic and religiously sensitive support for racialised groups in Scotland. Health In Mind provides various mental health support options for individuals in need, like peer support, guided self-help, counselling and many more.

After contact with these organisations, individuals are then referred to the NHS or other support facilities when further psychiatric care is required. As it pertains to suicide support, the aforementioned organisations have generalised information on suicide. This information focuses on creating awareness on the growing burden of suicide, educating individuals on how to best support individuals who may be showing suicidal behaviour, and providing a help directory and contact details of agencies individuals can seek support from. With SAMH providing the most extensive suicide help directory. However, there appears to be no specialised suicide support suicide targeted at racialised groups.

Conclusion

To ensure the successful delivery of the Scottish Government national suicide prevention plan: Every Life Matters. Action 7 of the plan focuses on identifying and facilitating preventable actions targeted at "at risk" groups in Scotland. This works was done in response to the gaps in knowledge on the experiences of suicide ideation and completion in racialised groups. One of the key "at risk" group the action plan aims to engage. This work emphasises that exploring the experiences of suicide ideation and attempts in racialised groups is incomplete without exploring the full diversity of the mental health experiences of racialised groups in Scotland. Furthermore, it finds that effective suicide prevention in racialised groups cannot be addressed in isolation, but rather in conjunction with addressing the prevailing systemic issues that perpetuate unequal access to mental health services for racialised communities, and recognition that experiencing racism itself is a kay factor. Moreover, this work emphasizes the need for mental health agencies and related practitioners to acknowledge that mental health help-seeking behaviour in racialised groups, is significantly influenced by the ethnic variations of service users and the interaction between services users and services providers. Therefore, ensuring cultural competence and sensitivity of staff, and an ethnically diverse mental health workforce could dramatically improve the appropriateness of mental health services.

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